Hallux, Sesamoid,and First MetatarsalInjuries

Daniel K. Lee, DPM, PhDca,*, Gerit D. Mulder, DPM, MS, PhDc, FRCSTb,Alexandra K. Schwartz, MDa

KEYWORDS

� Hallux � Sesamoids � Metatarsal � Fracture � Turf toe

Hallux, sesamoid and first metatarsal injuries are common foot injuries and haveimportant implications in the biomechanical functionality of the first ray and foot.1,2

The hallux is essential for propulsion in normal gait. As part of the first ray, it is animportant contributor to normal locomotion. Any structure disruption or injury cancreate angular changes or arthritis, which can have biomechanical implications,including pain, disability, compensation, swelling, and reduced range of motion.3 Ina study reviewing amputation and replantation of the hallux,4 the pedographic studiesrevealed consistent changes in weight-bearing distribution of the feet with amputatedhallux, altering the load distribution of the foot.

ANATOMY

The anatomy of the hallux is different from that of the lesser digits. Besides the consis-tent two phalanx composition, its anatomy at the base of the hallux, at the first meta-tarsophalangeal joint (MTPJ), is unique and complex.5 Understanding of this anatomyis crucial in the diagnosis and treatment of hallux and sesamoids injuries.6 The firstMTPJ inherent stability comes from the complex network of ligamentous and intrinsicmuscular structures extending around the base of the proximal phalanx, the head ofthe metatarsal, and the sesamoids. The sesamoid complex consists of sevenmuscles, eight ligaments, and two sesamoid bones.7 In the plantar aspect of the firstMTPJ, there is a fibrocartilaginous structure, the plantar plate, which also providesstability to the MTPJ. This extends plantarly from the base of the proximal phalanxinto the head of metatarsal. It encompasses the capsule and the sesamoids as well.Medially and laterally, the corresponding collateral ligaments join this network of

a Department of Orthopaedic Surgery, School of Medicine, University of California, 350 Dickin-son Street, MC 8894, San Diego, CA 92103–8894, USAb Division of Trauma, Department of Surgery, School of Medicine, University of California, 200West Arbor Drive, San Diego, CA 92103–8896, USA* Corresponding author.E-mail address: dklee@ucsd.edu

Clin Podiatr Med Surg 28 (2011) 43–56doi:10.1016/j.cpm.2010.09.002 podiatric.theclinics.com0891-8422/11/$ – see front matter. Published by Elsevier Inc.

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soft tissue structures, including the abductor hallucis tendon along its medial side,adductor hallucis (transverse/longitudinal) tendons along its plantar side, and flexorhallucis brevis (medial/lateral) tendons along its plantar side. The morphology of thehead of the metatarsal varies from round to square shape. A prominent cristae, ridgeor crest divides the sesamoid grooves. Some may have absence of this crest.8 Boththe medial and lateral sesamoids are connected via the intersesamoid ligament. Inthe first MTPJ radiographic study, bipartite sesamoids occurred in 13.5% of 200feet with a 37% bilaterality.9 Congenital absence of sesamoids is rare.10–13 Sesamoidsusually ossify at approximately age 10 and usually the medial one is larger than thelateral. Biomechanically, both function to sustain the body’s weight/pressure,14,15 toact as pulley mechanism to the MTPJ, protecting the tendon of the flexor hallucislongus.

HALLUX FRACTURES

Hallux fractures are common injuries of the forefoot usually caused by direct impact orcrushing type of mechanism. Depending on the type of injury severity and location, anassociated nail injury may occur and complicate the treatment process of the osseousinjury. These are treated as open injuries and may require immediate surgical interven-tion via irrigation and debridement, infection control, and off-loading. In the presenceof a subungual hemotoma, decompression or nail removal may be performed. Nor-mally, nail bed injuries/lacerations can be repaired without further consequences,but if the nail matrix is damaged, an abnormal or absent nail growth can be ensuredpostinjury.Hallux fractures can occur to the distal phalanx and proximal phalanx with or

without intra-articular involvement into the interphalangeal or MTPJs (Fig. 1). A directaxial injury to the tip or tuff of the great toe usually can lead to distal phalanx injury,whereas a crushing type of injury can lead to both proximal and distal phalanges injury(Fig. 2). The treatment is based on the severity, displacement, and alignment factors ofthe fracture. When displaced, manipulation, distraction, and reduction maneuversunder sedation or local anesthesia, with or without finger trap devices, can be per-formed followed by immobilization and digital splinting. Comminuted and displaced

Fig. 1. Fracture hallux. Open reduction with internal fixation hallux.

Fig. 2. Distal phalanx fracture, multifragmented.

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intra-articular fractures of either phalanx may require surgical fixation. Often, stiffnessof the interphalangeal and/or MTPJs remains as residual consequence of the injury.Stave fractures of the first metatarsal were described by Cooperman. The are equiv-

alent to a Bennett fracture of the thumb metacarpal. These are uncommon injuries.This fracture in the foot occurs from loading of the medial cuneiform into the baseof the first metatarsal. The initial report recommended plaster immobilization. Giventhat this is an intra-articular fracture, however, open reduction with internal fixationis recommended to minimize the risk of post-traumatic arthritis.

TURF TOE INJURIES

Turf toe (TT) injuries are defined as plantar capsular ligament sprain or disruption of thesupporting soft tissue structures of the first MTPJ.9,16,17 The mechanism of injury isusually associated with hyperextension of the MTPJ but can also occur with valgusor varus stress and rarely with hyperflexion (Fig. 3).18–21 With the advent of artificialturf and lighter shoe gear, the incidence of TT in many sports (football, soccer, anddance) and trauma has increased since the late 1960s.22,23 TT injuries have beenreported (eg, soccer, rugby, tennis, track, basketball, wrestling, skydiving, andvolleyball).24

In a recent National Football League team study, the findings showed that TT injuriesare associated with decreased MTPJ motion (40.6� � 15.1� vs 48.4� � 12.8�;P 5 .04), increased peak hallucal pressures (535 � 288 kPa vs 414 � 202 kPa;P 5 .05), and association of the severity of symptoms or progression to first MTPJarthritis.25

Fig. 3. TT injury, hyperflexion. First MTPJ dorsal capsular tear. T2 MRI view.

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Patients often present with acute onset of pain at the first MTP joint. The pain maybe somewhat diffuse or more localized. There may be swelling and/or ecchymosis. TTand sesamoids injuries can be unrecognized or undiagnosed. The range of injuries canspan from simple sprain/strain/rupture of the plantar structures to dislocation. Themore severe injuries may limit athletes’ ability to push off, run, and/or pivot. Due toits extensive soft tissue disruption and damage, both TT and sesamoids can lead tochronic disorders, persistent pain, loss of push-off strength, progressive hallux andfirst MTPJ valgus or varus deformity, and arthritis. The incidence can be as high as45% of professional football players.22 Risk factors include advanced age, increasedweight, longevity in professional football, pes planus, increased preinjury anklemotion, and decreased preinjury MTPJ range of motion.22,26

The treatment options of TT injuries are based on the level of damage/injuryincurred, which can range from acute to chronic conditions. A careful and thoroughevaluation is essential in maximizing the treatment and successful long-termsequelae. A detailed physical examination of the anatomic structures and advancedimaging studies are essential components of this evaluation. Imaging should includeweight-bearing views of the injured foot and comparison films if needed, to assessfor possible sesamoid fracture, diastasis of a bipartite sesamoid, and proximal migra-tion of the sesamoid. A lateral stress view of the first MTP joint may identify an occultfracture of the sesamoid or unstable diastasis of a bipartite sesamoid. Capsular avul-sion fractures may also be seen. There may be impaction of the metatarsal head withassociated intra-articular fragments. Also, when available, continuous live fluoroscopyimaging is useful in visualizing the lack of motion of the sesamoids with ranging of theMTPJ. Using contrast, arthrography can also be performed with a fluoroscopy or plainfilms. MRI is, however, the most used and provides the highest yield.27 In most acutecases, capsular disruption can be observed, and in most chronic cases, the associ-ated chronic articular damage and chondrolysis may also be observed.Initial treatment with anti-inflammatories, rest, ice, compression, elevation, and

protection is common in grade 1 injuries with microtears/ruptures. Gentle range ofmotion can commence less then 1 week post injury. Immobilization and protectionconsists of digital spica splinting, rocker boot, Morton extension, and modified stiffforefoot sole shoes/orthotics. If the swelling and skin condition allows, taping in thedirection opposite to the mechanism of injury can also be useful. Preinjury activities

Hallux, Sesamoid, and First Metatarsal Injuries 47

may be returned usually in less then 1 month. In grade 2 injuries with partial soft tissuetears/ruptures, the injury may progress further if not recognized and treated promptly.Pending the level of tear/rupture, MRI findings may or may not reveal fluid uptake ora positive finding. Most injuries can take 1 to 2 months for resuming preinjury activitiesand a few weeks more for athletic activities. In grade 3 injuries with full tear/ruptures,MRI findings are often positive, and prolonged immobilization and protection arenecessary for 3 to 6 months. Preinjury activities are resumed slowly, pending symp-toms and physical findings, but athletic activities are not resumed or are carefully per-formed after many months of recovery. The outcome is not predictive, however, forhealing and/or success in the long term; thus, surgical intervention is required.

SESAMOID INJURIES

Hallucal sesamoid injuries have been mainly reported among ballet dancers and invarious sports injuries.28–30 Although the hallux interphalangeal joint may be similarin structure as the other digits, authors have reported specific injuries associated inthis location (Fig. 4).31 Sesamoid injuries of the first MTPJ32 have been described invarious forms, including traumatic dislocations,33–44 TT injuries,45–47 stress/nonunionfractures/avascular necrosis,48–51 and open injuries (Figs. 5 and 6).52 Additional symp-toms at the first MTPJ can also result from inflammation, chondromalacia, flexor hal-lucis brevis tendonitis, osteochondritis dissecans, inflamed bursae, intractablekeratoses, infection, sesamoiditis, gout arthropathy, and rheumatoid arthritis.53

Surgical intervention of TT and sesamoids injuries are indicated once all nonopera-tive options fail. Recently, the advent of bone stimulation, via pulsed electromagneticfield therapy, has given hope to many patients for salvaging sesamoids from surgicalrepair attempts or excisions. Most cases seldom require surgery. Medial and lateral

Fig. 4. Hallucal sesamoid.

Fig. 5. CT scan of sesamoid fracture, medial, axial and sagittal views.

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capsule repair are common in these situations. Proper alignment at the hallux inter-phalangeal joint and MTPJ is crucial for optimal functionality. Articular damage repairand chondroplasty are also performed when indicated. Often, a type of bunionectomyprocedure, along with above procedures, is referred. Hallucal or MTPJ sesamoidsrepair, partial removal, partial resection, or complete removal is also considered inthe presence of sesamoids injuries (Fig. 7). Adjuctive procedures are also common:abductor/adductor tendon transfer, capsular interposition, osteotomy, andextensor/flexor tendon transfers. It is imperative to discuss the long-term sequelaeof these conditions with patients, which may prompt further surgical interventions:sesamoidectomy, hallux interphalangeal joint, and/or first MTPJ arthrodesis,amputation.

Fig. 6. Sesamoid fracture, lateral, multifragmented, chronic.

Fig. 7. Sesamoid fracture, lateral, plain films, bone scan, postoperative plain films, andclinical incisional approach.

Hallux, Sesamoid, and First Metatarsal Injuries 49

METATARSAL FRACTURES

Because of the importance of the first metatarsal in the biomechanics of gait and footfunction, malreductions of this bone are generally tolerated less than other metatar-sals. The first metatarsal is wider, shorter, stronger, and more mobile than the remain-ing metatarsals. Most of these fractures are due to a direct blow, crush, axial load, or,

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less often, a twisting mechanism. Due to the frequent direct injury mechanism, it isimportant to rule out open fractures. Patients present with pain, dorsal swelling,ecchymosis, and, most often, inability to walk. The skin should be carefully evaluatedto rule out an open fracture. There is point tenderness over the fracture. Alignment maybe abnormal in terms of length and rotation. Initial radiographs should include antero-posterior, oblique, and lateral views of the foot. In cases of suspicion of more severeinjuries, for instance, a Lisfranc injury, stress views or weight-bearing views are help-ful. CT scan is not often indicated, except for possible intra-articular fracture assess-ment, including those with impaction. Nonoperative treatment with a short leg cast orremovable boot is indicated for nondisplaced, simple fracture patterns without asso-ciated injury. Frequent radiographs should be obtained in the first several weeks toensure no displacement occurs. Operative treatment is indicated for open fractures,fractures associated with skin tenting, shortened fractures, unstable fracture patterns,intra-articular fractures, or fractures with greater than 10� of plantar angulation.54

Operative treatment consists of open reduction and stable internal fixation, most oftenwith minifragmentary or small fragmentary screws and/or plates. Low profile plates arehelpful to avoid tendon irritation (Figs. 8–10).Stress fractures of the first metatarsal have been reported. The second and third

metatarsals are the most common sites of metatarsal stress fractures, but the firstmetatarsal accounts for approximately 7% to 8% of metatarsal stress fractures.55

These are injuries as a result of overuse and repetitive injury. They are commonlyseen in military recruits, dancers, and runners. Excessive pronation, lower-extremitymalalignment, and leg length discrepancy may predispose to first metatarsal stressfractures. Pain occurs with weight bearing and subsides with rest. Initial radiographsmay be negative. After 2 to 3 weeks, there may be radiographic evidence of healingand callus formation. An MRI or bone scan is the definitive study if initial radiographs

Fig. 8. Metatarsal fracture: isolated base fracture, preop and postoperative views.

Fig. 9. Metatarsal fracture: multifragmented, preop and postoperative views.

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are normal and there is a high suspicion. Treatment is immobilization and nonweight-bearing for 6 to 8 weeks. Patients may then begin low-impact activity but shouldrefrain from any sports until they have has regained pain-free ambulation and full rangeof motion, strength, and proprioception.

WOUNDS AND LACERATIONS

One of the most common sites of ulceration and laceration on the foot is the hallux. Asthe largest and perhaps the most biomechanically important of the digits of the foot,the hallux is subject to varying injuries, including ulceration from pressure, lacerationsfrom trauma, and nail-related injuries and/or complications.Loss of the hallux at the level of the MTPJ may affect propulsion, balance, and

weight redistribution, thereby contributing to transfer and other lesions of the foot.A variety of deformities result in the digit becoming more susceptible to tissuebreakdown. Ambulation on a severely plantarflexed hallux may result in a distaltip or distal plantar lesion. Shoe modification or specialized walkers provide minimalpressure relief, particularly when a rigid deformity is present. Off-loading through theuse of crutches or a wheelchair is impractical. Contact casting may have little to noeffect on such a deformity. These types of wounds are best addressed throughsurgical selection with flexible deformities corrected through tendon releases andrigid deformities modified through bone excision or positional modification. Oncethe pressure has been relieved, wounds respond, in the absence of infection, tomost topical dressings without the need for advanced therapies. Even afteraddressing the underlying anatomy and physiology, selection of appropriate shoe-gear is imperative.

Fig. 10. Tarsometatarsal fracture/dislocation: preoperative, intraoperative, and postopera-tive views.

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Hallux deviation, when present with hallux valgus or other MTPJ anomalies, isa significant contributor to medial and distal hallux ulcer development. In scenarioswhere themetatarsal is involved, the clinician must determine the relevant biomechan-ical forces and type of anatomic abnormality before attempting to correct the problem.

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Surgical intervention, when not contraindicated, provides the most rapid means ofcorrecting and permanently addressing the problem. Splints and positional devicesare only temporary measures and may be rendered ineffective unless a patient iswearing the device at all times. Wounds occurring at the medial MTPJ are commonlyfound in the presence of hallux valgus deformities. Determining the depth of thewound and involvement of underlying structures assists with dressing selection.When tendon or bone involvement is present, osteomyelitis must be ruled out. Ampu-tation of the hallux may be necessary yet may not significantly affect gate if the meta-tarsal head is left intact.The nail and nail bed may become ingrown and infected as a result of poor nail care

and/or poorly fitted shoes. When ingrown, the nail border should be excised down tothe level of thematrix. A matrixectomymay be considered for recurrent ingrowth of thenail. Determining adequate vascular flow to the digit as well as a patient’s medicalstatus and ability to heal must be established before nail removal. Patients shouldbe forewarned of the high risk of amputation in cases where re-establishing the bloodflow is not an option. Amputation should be limited to the hallux whenever the meta-tarsal is not involved.Trauma to the hallux may result in deep tissue damage, infection, and fractures.

Standard radiographs are recommended during the initial examination with possibleMRI or labeled white blood cell scan radiography when osteomyelitis is suspected.Fractures of the hallux, when nondisplaced, heal well with splinting. Major displace-ment may require surgical intervention. When the joint capsule has been compro-mised, surgical intervention is usually the only treatment option.

SUMMARY

In summary, the hallux is a source of many injuries. Hallux fractures, TT injuries, andsesamoid injuries are common yet challenging because of the myriad possible etiolo-gies and complex anatomy. Unstable, displaced, open, and intra-articular fractures ofthe first metatarsal should be treated operatively, most often with open reduction andinternal fixation to restore proper anatomy and function. A high suspicion should behad for athletes with first metatarsal pain to rule out stress fracture. An MRI or bonescan is diagnostic if plain radiographs are negative. A few of the causes of woundsand lacerations have been discussed; however, clinicians must develop a comprehen-sive differential diagnosis that may include other lesions, including, but not limited to,melanoma of the skin (and occasionally below the nail bed), tinea, skin carcinomas,hyperkeratosis diseases, and other dermatologic conditions. Biopsies should alsobe considered when lesions do not respond to traditional approaches to care, in thepresence of abnormal tissue, or when wounds have been open for greater than 3months without response to appropriate care. As discussed previously, a thoroughexamination and evaluation and advanced imaging techniques are essential. Whennonoperative measures fail, surgical interventions are indicated. When addressingathletes, the return to nonathletic and athletic activities needs to be discussed andcustom tailored based on the sports and/or condition of the athlete, due to thepossible long-term sequelae associated with these conditions.

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